Primary Sclerosing Cholangitis (PSC) is a common indication for liver transplantation. However, PSC is a recognised risk factor for cholangiocarcinoma (CCA) and the investigation of concerning strictures in PSC is a significant part of focus of investigations in to PSC. This is vitally important in those undergoing transplantation, where currently, in the UK, having CCA is an exclusion criterion for transplantation. Cholangioscopy is a recognised tool used in this scenario. Studies have shown that cholangioscopy is the most useful tool in the detection of CCA in PSC but it still only has a sensitivity of 65%¹.  This is significant lower than when compared to non PSC indeterminate biliary strictures assessment which has a sensitivity as high as 94%². These studies show the specificity is similar between PSC and non PSC groups at 95-97%.

This study evaluates the diagnostic performance of cholangioscopy-guided assessment in patients with concerning biliary strictures undergoing assessment for liver transplantation on the background of PSC. To the authors knowledge there is no published data addressing this specific question.

This was a retrospective, single-centre study including consecutive patients, who had PSC as the underlying liver disease, who underwent Liver transplantation assessment. The study looks at patients under assessment from January 2020 to September 2025. All patients had biliary strictures considered suspicious for malignancy based on cross-sectional imaging. Cholangioscopy was performed using the SpyGlass DS II system (Boston Scientific), and all biopsies were obtained under direct visual guidance. 

108 patients with PSC were worked up for liver transplantation during this time. 26 patients had an ERCP as part of their assessment and 15 of these had cholangioscopy. 2 (13.3%) were found to have CCA and so not listed. 1 was delisted for another reason. 1 (8.3%) is currently on the waiting list and 11 have been transplanted. Of these 1/11 (9.3%) was found to have CCA on their explant. Of the 93 patients who did not have cholangioscopy 6 (6.5%) had CCA on their explant and only 1 of these had had an ERCP, which did not detect the CCA .

In this cohort pre-transplant cholangioscopy has a sensitivity of 66.7% and a specificity of 100%. Its positive predictive value is 100% and its negative predictive value is 91.7%. This is compared to a negative predictive value of 93.5% for those patients being assessed for transplant who were deemed not to need cholangioscopy. The similar negative predictive value for patients who are deemed to need cholangioscopy and those who are deemed not to need cholangioscopy is evidence of the benefit of cholangioscopy in this settings.

Due to the rarity of this scenario and the ethical difficulties involved conducting a randomised controlled study will be challenging to power. Therefore, moving forward there is a need for the liver transplant centres to pool their data on this cohort of patients to further assess the role of cholangioscopy in the assessment of potential liver transplant recipients with PSC.

These results indicate that cholangioscopy is a useful tool to help minimise the risk of transplanting patients with PSC who have a concurrent CCA.